Provider Demographics
NPI:1780802504
Name:HEALING GRACE INTERNAL MEDICINE & PEDIATRICS, LLC
Entity type:Organization
Organization Name:HEALING GRACE INTERNAL MEDICINE & PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-671-9309
Mailing Address - Street 1:6821 PINES RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-2547
Mailing Address - Country:US
Mailing Address - Phone:318-671-9309
Mailing Address - Fax:318-671-9311
Practice Address - Street 1:6821 PINES RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2547
Practice Address - Country:US
Practice Address - Phone:318-671-9309
Practice Address - Fax:318-671-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023335207K00000X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1494046Medicaid